Wheelchair Selection and Training: Teaching and Guiding Practitioners and Consumers
The following is a book review of five (5) books related to wheelchair technology. The book review is reprinted here with the written permission of the American Occupational Therapy Association. This article was originally published in the January/February edition of the American Journal of Occupational Therapy.
The Manual Wheelchair Training Guide
The Powered Wheelchair Training Guide
The Wheelchair Evaluation: A Practical Guide
Wheelchair Selection and Configuration
Wheelchair Mobility: A Handbook
Choosing a Wheelchair: A Guide to Optimal Independence
We are in a time of innovation with assistive technology brought about by partnerships between rehabilitation specialists and engineers who have been joined by expert users and other consumers. It is estimated that assistive technology uses have doubled over the past 20 years (Scherer & Lane, 1997), owing to performance and participation needs for adaptations in manipulation, mobility, and communication. One of the most prolific areas of new development is seen in wheelchair mobility, where choices for styles, features, and controls continue to evolve. The wheelchair industry itself has grown into a competitive half-billion dollar industry serving a growing market of nearly 2 million wheelchair users in the United States alone (Russell, Hendershot, LeClere, Howie, & Adler, 1997).
Consumers face decisions about being supported in a prolonged sitting posture and having an appropriate mobility base and controls that enable them to function in their environment while engaged in their daily occupations. Practitioners are called on to guide the selection process and provide training, often through teaming with technical experts (therapists, engineers), product suppliers (manufacturers, vendors), and expert users.
Selection of an appropriate wheelchair is commonly viewed as complex, a by-product of different theories of seating and mobility as well as abundant options to address users' needs, skills, and resources. Persons who select and use wheelchairs do so because of acute and, for them, novel circumstances or because of inevitable change due to developmental or chronic disability. Decision making is difficult because of adjustment to change, the unknown or inexperienced reality of new impairments, and an array of personal and social issues. Selection is inevitably constrained by costs and access to resources.
Reviewed in this article are recently published books that address wheelchair selection and training. Appropriate to modern times, the books guide practitioners and students, including occupational therapy practitioners, consumers, wheelchair users, or all parties. Some of these books focus primarily on wheelchair designs and seating, whereas others give detailed training of wheelchair maneuvering skills.
Given the development of theory, principles, and products and the maturing experiences of users, what do occupational therapy practitioners need to focus on in their initial training and continuing education competencies? Practitioners should attend to mobility and seating principles and products as well as to the consumer perspective about wheelchair use and lifestyle. Books addressing practitioner skills as well as expert users' recommendations are beneficial. The books reviewed here address critical issues of initial device selection, checkout and fitting, training, maintenance, and reevaluation of needs that often renew a selection process. Some expert users provide pragmatic advice about learning and adjusting to wheeled mobility.
Wheelchair Selection and Configuration by engineer Rory Cooper is particular well suited for classroom and clinical training of therapists and rehabilitation engineers. The text applies engineering and design principles to address the common or specialized mobility and positioning needs. Cooper reviews foundation concepts that are helpful for occupational therapy practitioners to understand when problem solving specific wheelchair and seating challenges with rehabilitation engineers, designers, and technicians at levels of manufacturing and local service delivery.
The book suggests evaluation strategies used with wheelchair users but does not provide specific review of what therapists are typically doing in their functional assessments that consider issues stemming from musculoskeletal, neuromuscular, and cardiopulmonary impairments. The emphasis is on application of engineering techniques to address the challenges to effective wheelchair use positioning and pressure, mechanics of mobility and transport, self-propulsion and electronic control features, and maintenance needs.
Cooper bases the approach on how user needs can be addressed within a product development system that is becoming more standardized. A very helpful review is provided of new and developing standards for measurement and product specifications that are being organized through assistive technology and engineering organizations (e.g., Rehabilitation and Assistive Technology Association of North America (RESNA), American National Standards Institute (ANSI), International Organization for Standardization (ISO). These guidelines help in matching body measurements to seating and wheelchair dimensions. Standards also begin to permit effective product comparison and contrast. This comprehensive text would serve as a state-of-the-art resource for therapists who are already skilled in evaluation and who provide specialized seating and wheelchair mobility services in clinical settings. Illustrations and photographs are well designed and provide good teaching examples useful for both classroom and client education.
The Wheelchair Evaluation: A Practical Guide by Mitch Batavia, a physical therapist, provides clinicians and students in health care fields with a practical, concise approach to evaluating and recommending a wheelchair to a client. This nearly pocket-sized book is organized into convenient sections. The first section addresses evaluation of the user (e.g., client history taking and review of contexts of wheelchair use, physical examination, skills assessment). The next section covers wheelchair components (e.g., mobility base, seating system and components), and the last section reviews common problems and makes troubleshooting suggestions. Also included are appendixes on ethics, client satisfaction, body shape considerations in fitting, skill training needs for caregivers, and a product directory for manufactures and suppliers.
The book is most appropriate for organizing an evaluation and as a quick reference for addressing and problem solving specific mobility and seating issues in clinical practice. A good deal of information is presented in outline or list format that enables inclusion of many issues, but with little depth. At the end of each chapter are suggestions for educational learning activities to augment family and student training. These suggestions may be useful for classroom problem-solving exercises or fieldwork-level discussion and training. In contrast to Cooper's text, illustrations in Batavia's book are few and rather rudimentary. References are cited for additional study, but many ideas are based on the author's experiences in practice. The book is best suited for clinical training and practice. If used for classroom instruction, additional information would be necessary to augment theoretical foundations and to supplement technical understanding behind engineering design of devices and interface with human tissues and structures.
Gary Karp's book, Choosing a Wheelchair: A Guide to Optimal Independence, guides the selection of wheelchair systems and advises new wheelchair users about wheeling technique, style, and safety. The book is geared for consumers, advising them on their role in the selection process and what to expect from team members, including occupational therapy practitioners. Karp, a man with spinal cord injury, is an experienced manual wheelchair user who has professional design training and business applications. The book is one in a series of client-centered guides from this publisher.
Karp writes in a narrative style, avoiding or clarifying the terminology or jargon common to professional medical literature. He uses a reader-friendly style of making a point and cites a quote from an experienced user or professional provider to bring focus on an issue. The text organizes practical advice on selection of the mobility base, seating, cushioning and other features that affect comfort, function, convenience, and safety. Convenient checklists summarize the options to be considered in selection of either manual or power wheelchair components. The personalized discussion of wheeling and function is expressed by the author's analogy of being effectively mobile on wheels as a state of "Zen Wheeling" (p. 147).
This book will be quite useful as a reading for classroom or fieldwork students, particularly if they will be recommending such a resource to a client or family members who are making wheelchair decisions. The book is very well suited for the consumers who wish to educate themselves about working with professionals and suppliers and who will be adapting to primary wheelchair mobility. Experienced seating and mobility practitioners should read the book to gun an appreciation for describing wheelchair features in terms appropriate for users and how professional opinion contrast users' experiences.
Croteau, a manual wheelchair user with spinal cord injury, developed Wheelchair Mobility: A Handbook for new manual wheelchair users and for persons engaged in training (e.g., occupational therapy practitioners, physical therapy practitioners). Written to the wheelchair user, it guides the reader in learning and teaching mobility skills appropriate for protecting the body, becoming efficient and safe in propulsion, and handling common conditions within the mobility environment (e.g., ramps, surfaces, slopes, curbs, stairs, doorways). The author also suggests that "good looks" (p. 4) are important, and throughout the text, he shares insights, humor, and other viewpoints that reflect his personal experiences. Wheeling skill training is explored, making note of appropriate wheelchair selection and fit. The final section discusses wheelchair sizing and component part adjustments that may optimize function. Wheeling recommendations are oriented to getting started and then guide the user in advancing skills with realistic challenges and technique suggestions.
The manual is entirely based on veteran user recommendations and training experiences for persons with spinal cord injury who would be using self-propulsion techniques. Practitioners could use the manual to learn skills themselves and to better organize instruction for clients. A long learning curve is described as being necessary, and the manual could be used to guide the new wheelchair user with spinal cord injury from initial inpatient time through community lifestyle change. No references are cited in this book, and some of the suggested techniques contrast with other training sources. As with seating and mobility base guidelines from other books, practitioners should discriminate among differing suggestions and use flexibility in applying recommendations.
The final book in this review, The Manual Wheelchair Training Guide, is another that provides a thorough set of recommendations for users of manual wheelchairs. The text is a compilation of interviews and focus group discussions and is edited by professionals and experienced wheelchair users. The authors, Axelson, Chesney, Minkel, and Perr, an interdisciplinary group of assistive technology professionals, were funded by a grant from Paralyzed Veterans of America (PVA) and are developing a power wheelchair training guide. This book orients manual wheelchair users to different types of wheelchairs, mobility, and seating components that can be adjusted; needs and skills in asking for assistance; learning chair operation; navigation and emergency skills; transportation and trip planning; and body mechanics safety. Written for the user, the manual offers specific instruction and advice by way of bulleted procedures and frequent uses of diagrams. Safety is emphasized, and recommendations for how to ask for use of spotters and other helpers while learning or performing certain maneuvers is explicitly discussed.
Again, practitioners could use this book to instruct themselves in manual wheeling techniques and use specific outlines for skills training. Unlike the shorter manual by Croteau, Axelson et al.'s book is not necessarily sequential for training purposes. Therapists would need to select specific skills to customize training with a particular client. Although developed by the PVA, no specific reference to spinal cord injury is made, making the manual appropriate for various types of persons who may be using manual wheelchairs.
This collection of books covering wheelchair selection and adjustment, as well as user training, gives evidence of assistive technology partnerships that are becoming increasingly balanced between professionals and consumers. Although enthusiasm for new options and informed decision making is found in each book, pause must be taken to acknowledge the challenges that wheelchair and other assistive technology users face. Although options and uses of assistive technology have increased, negligible change has occurred in employment and economic viability of those with disability (National Organization on Disability, 1998). For example, only 22% of wheelchair users are employed (Stoddard, Jans, Ripple, & Kraus, 1998). Failure of assistive technology to become better integrated and accepted into schools and workplaces and higher than expected rates of assistive technology abandonment should lead to a rededication of national and local programs to make consumers a focal point of education about products, services, and industry development.
With the emphasis on outcomes today, practitioners face the dilemma of assistive technology effectiveness. Although not explicitly addressed by the authors in this series of books, themes related to effective outcomes with wheelchair use are commonly described and relate to issues of safety, comfort, ease and efficiency of use, effective maintenance, and costs along with satisfactory performance and community participation.
Brian J. Dudgeon, MS, OTR
Lecturer, Division of Occupational Therapy
National Organization on Disability. (1998, July 23). Survey on participation and attitudes: Americans with disabilities still face sharp gaps in securing jobs, education, transportation and many areas of daily living. (Retrieved from http://www.nod.org/content.cfm?id=1035
Russell, J. H., Hendershot, G. E., LeClere, F., Howie, L. J., & Adler, M. (1997, November 13). Trends and differential use of assistive technology devices: United States, 1994. (Advance Data From Vital and Health Statistics, No. 292).
Scherer, M. J., & Lane, J. P (1997). Assessing consumer profiles of "ideal" assistive technologies in ten categories: An integration of quantitative and qualitative methods. Disability and Rehabilitation, 19, 528-535.
Stoddard, S., Jans, L., Ripple, J., & Kraus, L. (1998). Chartbook on work and disability in the United States, 1998. (An InfoUse Report). Washington, DC: National Institute on Disability and Rehabilitation Research.
Last Updated: 3-2-2006